The many questions we still need to answer on integration

For many integration is the only way to deliver truly joined up care; for an increasing number of people it is the silver bullet to break down the decades old institutional barriers between health and local government; and for some it is the next model to be imported from overseas to retrofit the “out of date” NHS.

The King’s Fund and Nuffield Trust have been commissioned by the Department of Health to “help support the development of a national strategy for the promotion of integrated care”. The NHS Future Forum’s latest task is to examine how the idea can be adopted more widely. Meanwhile, Monitor, sniffing the prevailing policy wind, talks openly of “competition-free zones” and “safe harbours” to allow integrated models to develop.

It seems that whatever the question or issue, “integration” is the answer.

But what sort of integration: vertical integration between primary and secondary care, horizontal integration between health and social care, even between commissioners and providers or all three? Need integration be delivered by organisational merger or pooled budgets? Or can it be provided by that most hackneyed of phrases, “joint working”, or plain and simple cooperation?

Can integration only be delivered by the public and third sectors or does the private sector have a, maybe significant, role to play?

Are the not-for-profit integrated care operations, all the rage in the US, the right model or is it social enterprise? Anyone had a look at Finland, Sweden or Spain? Almost every approach has some high profile fans.

And how much does the NHS need to re-engineer its incentive structure to make integration, whatever it is decided to mean, happen?

The flagship local government “whole place” initiative to build “community budgets” is tip-toeing around the integration of health services. Social care minister Paul Burstow told a recent King’s Fund meeting that many in the public sector thought it was too “risky” to integrate services. 

Does the behaviour encouraged by payment by results provide an insurmountable barrier to integration? Will the any qualified provider policy fragment provision to the extent that integration is impossible or will clever clinical commissioners and their support organisations use their muscle to stitch together integrated networks that deliver choice and consistency as Charles Alessi argues? 

We can look towards the South West for the answers to many of these questions. The region has gained significant autonomy by performing ahead of the curve and showing little tolerance to financial indiscretion. This has fostered a culture of innovation. Indeed, the South West already possesses the poster-boy for NHS and social care integration, Torbay and Southern Devon Care Trust.

Like all health economies it has its challenged organisations, but our story on the future of Weston Area Health Trust shows the wide range of innovative solutions being considered.

There are, of course, other sites of emerging integration throughout the NHS. Weston, for example, is examining the model being rolled out in Herefordshire’s Wye Valley.

But a note of caution is needed. Integration will not prove the panacea to all NHS ills. The sometimes contradictory and destructive nature of the reforms is throwing any kind of supposed alternative into an unrealistic golden light. Services can be “integrated” for a wide range of motives – not all associated with improving public health and wellbeing – and with varying degrees of effectiveness. This danger is especially great in a period when money is tight.

Before the NHS moves forward we will all need to learn the difference between good and bad integration.